Peripheral Vascular Disease Flashcards
Indications for carotid bifurcation imaging:
- ) stroke risk factors: neruo symproms (TIA), moderate-severe PVD, retinal exam findings
- ) Symptomatic patients: contralateral weakness/sensory deficits
Amourosis Fugax
Shade coming down over the eye
Hollenhorst plaques
cholesterol deposits on the retina.
Carotid bruits
More predictive of CAD/MI risk than stroke. Sensitivity is poor but specificity is high
Carotid Artery Disease treatment
treat HTN, hyperlipidemia, DM. Smoking cessations. Aspirin or clopidogrel.
Carotid Artery indications for surgery
if greater than 70% occluded. Carotid endarterectomy is preferred but a stent can be used for symptomatic patients with larger risk factors for surgery.
Aneurysm
Abnormal dilation of a vessel. 1.5-2 times the normal size.
Aortic Aneurysm
Due to degeneration and remodeling of the aortic wall. Usually atherosclerotic.
Ascending aortic aneurysm symptoms
Compression (swelling in head/arms), pain (chest/neck/back), hoarseness (RLN), aortic valve regurgitation.
Arch/Descending aortic aneurysm symptoms
Wheezing, coughing, SOB, hemoptysis, hoarseness, dysphagia, chest/back pain.
Aortic aneurysm Surgical indications
larger than 5-6cm. Marfans at 4-5cm. Factors such as location and involvement of other vessels.
Aortic aneurysm medical management
Beta-blockers, Angiotensin II receptor blockers (retards growth and lowers BP), statins, smoking cessation, BP goal of less than 140/90.
Aortic Dissection
Tear into the intima that penetrates into the media and splits longitudinally. Usually occurs in the thoracic aorta.
Aortic Dissection etiology
connective tissue disorder, aneurysm, HTN and trauma.
Aortic Dissection symptoms
Acute onset of tearing pain in the chest or abdomen. HTN (often discrepent) and anxiety. Neuro changes. Distal ischemia. acute cardiac failure. hypotenstion and shock. Hoarseness.
Type A Aortic Dissection
Ascending aorta +/- arch
Type B Aortic Dissection
Descending aorta only
Aortic Dissection diagnosis
spiral CT with contrast
Aortic Dissection complications
rupture, thrombosis/ischemia, aneurysm, re-enter (best case) or continue to extend.
Aortic Dissection Xray
Widened mediastinum, loss of aortic knob, globular heart, pleural capping or effusion.
Aortic Dissection risk factors
HTN, connective tissue disorder, pregnancy.
Aortic Dissection medical management
Reduce systolic BP to 100-120. Beta blockers THEN vasodilator (nipride). Pain control.
Aortic Dissection type A management
emergent surgery.
Aortic Dissection type B management
medical therapy unless complicated (failure of medical management, uncontrollable pain, progression, marfans)
AAA screening indications
Anyone with a family history needs an US.
AAA surgical indications
if greater than 5.5 cm or is expanding more than 0.5cm in 6-12 months.
AAA medical management
Follow up every 6-12 months.
AAA symptoms
Usually asymptomatic. Most common complaint is back pain.
Ruptured AAA symptoms
Abdominal pain, pulsatile tender abdominal mass, hypotension.
Chronic Aorto-iliac occlusive disease risk factors
Young, female, smoker, hyperlipidemia, congenitally smaller aorta, chronic lower limb ischemia.
chronic Aorto-iliac occlusive disease diagnosis
Angiogram or MRI/MRA
Chronic Aorto-iliac occlusive disease treatment
endovascular or aortic bypass surgery.
Acute Aorto-iliac occlusive disease cause
Vascular emergency, saddle embolism at bifurcation or in-situ thrombolism of already diseased segment.
Acute Aorto-iliac occlusive disease symptoms
Neuro deficit including paralysis, absent femoral pulses.
Acute Aorto-iliac occlusive disease treatment
Quick imaging and operation (aorto-bifemoral bypass).
Popliteal aneurysm
Rare, older males with co-morbidities. Greater than 2 cm pulsatile mass often with angulation.
Popliteal aneurysm complications
thrombosis, embolization (black toe syndrome), claudication, pressure symptoms.
Peripheral Arterial Disease (PAD)
Chronic arterial insufficiency of the lower extremities. Most common form of peripheral vascular disease. Athersclerotic in nature and are progressive.
Peripheral Arterial Disease (PAD) symptoms
claudication, rest pain (less than 50mmhg in the leg) usually in toes and dorsum of the foot. Dependent rubor. hair loss, atrophic skin, nail changes, ulcers. Pallor when elevated. Cool skin. Delayed capillary refill.
Leriche Syndrome
decreased femoral pulses, impotence, butt/thigh claudication (aorto-iliac disease)
Ankle Brachial Index
ankle systolic divided by the higher brachial systolic.
Ankle Brachial index classifications
normal=1 mild=0.7-0.99 Moderate=0.5-0.7 severe= less than 0.5 If over 1 think DM due to calcified vessels.
Peripheral Arterial Disease (PAD) most common veins affected
superficial femoral and popliteal.
Claudication classification
mild= greater than 2 blocks Moderate= one block Severe= less than one block
Peripheral Arterial Disease (PAD) treatment
Walking regimen, smoking cessation, lipid-lowering therapy, aspirin (or clopidogrel)
Treatment for sever claudication
pentoxifylline (trental) 400mg TID to help reduce viscosity and help the RBC move through the capillaries.
Cilostazol (pletal): phosphodiesterase III inhibitor shown to be more effective than trental
Peripheral Arterial Disease (PAD) indications for surgery
affecting their lifestyle, rest ischemia, limb threat
Limb threat
ABI that is less than 0.2
Acute Artery Obstruction symptoms
Pain, pallor, paresthesia, paralysis, pulselessness.
Acute Artery Obstruction Causes
Thrombus, embolism, hypercoagubility, external compression or artery (thoracic outlet syndrome).
Acute Artery Obstruction treatment
emergency surgery or thrombolytic infusion. Heparin is given right away to keep it from getting worse.
Compartment Syndrome Causes
Common after reperfusion of an ischemic limb. Usually in the calf.
Compartment Syndrome symptoms
out of proportion pain, passive stretch pain, parasthesias, pokliothermia, paralysis, pulselessness
Compartment Syndrome treatment
fasciotomy with delayed closure.
Varicose veins cause
defective venous valves. Seen in people who are on their feet a lot.
Varicose veins symptoms
Tired, heavy sensation. can be painful/burning/achy. Relieved with elevation. Can also have stasis dermatitis and edema.
Varicose veins treatment
compression stockings, sclerotherapy, laser therapy, vein stripping.
Chronic venous insufficiency Causes
valvular incompetence or some sort of damage (DVT or trauma).
Chronic venous insufficiency treatment
elevation and compression. wound care with an unna boot if needed. Possible need for diuretics or antibiotics.
Virchow’s triad
Stasis, vessel wall injury and hypercoagubility. Three things needed for thrombosis.
Venous thromboembolism risk factors (chronic)
Chronic diseases (CHF, IBS, nephrotic syndrome), malignancy, obesity, antiphospholipid antibody syndrome, advanced age, smoking, myeloproliferative disorders
Venous thromboembolism risk factors (transient)
surgery (ortho), trauma, immobilization, central lines, hospitalization, infections, prolonged travel.
Venous thromboembolism risk factors (female specific)
pregnancy, post-partum, hormonal contraceptives, hormone replacement therapy.
Venous thromboembolism risk factors (inherited)
factor V leiden mutation, prothrombin mutation, protein S deficiency, Protein C deficiency, antithrombin deficiency.
DVT presentations
Can be asymptomatic. Swelling, pain, warmth, redness/dicoloration, palpable cord. Homan’s sign (not specific or sensitive).
Wells criteria for DVT factors
cancer, immobilization, bedridden, tenderness, leg swelling, pitting edema, collateral veins.
Wells criteria for DVT scoring
2-8 high probability
1-2 moderate
-2-0 low
D-Dimer
Degradation product of cross-linked fibrin. Greater than 500 ng/ml. Seen in almost all patients with a DVT/PE but not specific.
D-dimer incications
Used to rule out DVT/PE. Used when suspicion is low or when ultrasound is negative. A negative D-dimer is insufficient as a stand-alone test to rule out DVT if suspicion is high.
Contrast venography indications
Used when other studies are inconclusive. Not used as initial screening tool because it is invasive.
Impedance plethysmography
measures small changes in electrical resistance that reflect blood volume changes. Indirectly indicates a DVT
Impedance plethysmography indications
Not first choice because while it is non invasive it is not widely available. Is preferred test for recurrent DVT though.
Compression ultrasound indications
test of choice for high suspicion of DVT. Not great for proximal veins though.
Low probability of DVT diagnostics
First D-dimer and if positive then ultrasound. If negative DVT is ruled out.
High probability of DVT diagnostics
Ultrasound if positive=DVT. If negative then do a D-dimer if negative=no DVT. If the D-dimer is positive have the patient follow up in a week.
DVT Treatment
Anticoagulation therapy, Early ambulation, prevention (compression stockings)
Superficial thrombophlebitis
No edema and don’t need anticoagulation. Not a DVT.
Pulmonary embolism
obstruction of the pulmonary artery or one of it’s branches by material that originated somewhere else. DVT is the most common cause. More common in males.
Hemodynamic instability
Systolic BP less than 90mmHG 40mmHg within 15 minutes. More likely to die of the PE.
PE symptoms
DYSNPNEA and PLEURITIC PAIN, DVT symptoms, cough (hemoptysis).
PE Signs
TACHYPNEA, tachycardia, decreased breath sounds, accentuated pulmonic component of S2 and JVD.
Hemodynamically stable diagnosis of PE
Wells criteria for PE, D-Dimer, and diagnostic imaging (CTA)
Hemodynamically unstable diagnosis of PE
EKG to make a presumptive diagnosis of PE
Wells criteria for PE
DVT symptoms, tachycardia, immobiliation, previous DVT, hemoptysis, malignancy.
Wells criteria for PE scoring
greater than 4=PE likely
Less that 4= PE unlikely
Pulmonary angiography
Historically was the gold standard for PE diagnosis but not now. Too invasive with high IV contrast load.
CT Pulmonary Angiography
Test of choice for PE diagnosis. sensitive and specific. Non-invasive. Contraindicated if contrast allergy or renal dysfunction.
Ventilation-perfusion scan
Sensitive but not specific. High number of false positives. Used for patients with contrast allergy or renal dysfunction. Also used for those that had normal chest radiography.
EKG for PE
Non-specific ST-segment and T-wave changes. S1Q3T3 pattern (10%).
Chest Xray for PE
not sensitive or specific but still done on everyone. Hamptons hump (opacity) and westermark sign (oligemia)
PERC Rule
Alternative to using D-dimer to rule out a PE. Has to have all eight: less than 50 yo, HR less than 100, sats above 95%, no hemoptysis, no estrogen use, no prior DVT/PE, no unilateral leg swelling, no recent surgery/trauma/hospitalization.
Lovenox
SQ low molecular weight heparin.
Coumadin
oral warfarin
Fondaparinux (arixtra)
SQ factor Xa inhibitor
rivaroxaban (xareltol)
Oral factor Xa inhibitor
apixaban (eliquis)
Oral factor Xa inhibitor
edoxaban (Savaxsa)
Oral factor Xa inhibitor
dubigatran (pradaxa)
Oral direct thrombin inhibitor
Initial anticoagulation therapy
First ten days. SQ LMW heparin, SQ fondaparinux or IV UFH (less common)
Initial anticoagulation therapy with UFH indications
severe renal failure or those more likely to need anticoagulation reversal IV UFH is preferred.
Initial anticoagulation therapy with SQ LMW heparin indications
pregnancy and malignancy
Long term anticoagulation therapy
Warfarin with a target INR of 2-3. Warfarin is slow acting so you need an additional anticoagulant until the warfarin is providing anticoagulation.
Long term anticoagulation therapy alternatives
Oral factor Xa inhibitors and oral direct thrombin inhibitors are used so patients don’t have to monitor their INR. But need to take into account the possible need for anticoagulation reversal (trauma, elderly, alcoholics).
Heparin reversal
Protamine (only parital with LMW heparin)
Warfarin reversal
vitamin K and fresh frozen plasma
Factor Xa inhibitor reversal
NONE
Direct thrombin inhibitors reversal
Idarucizumab is a brand new drug on the market.
First episode treatment duration
At least 3 months. If provoked anticoagulation therapy should continue until the risk factor is modified (pregnancy).
Indefinite anticoagulation indications
first/recurrent episodes of unprovoked DVT/PE especially with proximal DVTs. Underlying thrombophillia.
Protein C, S or antithrombin deficiency Lab indication
Consider if less than 50 years old and with a family history.
Factor V leiden or prothrombin mutation tests
PCR for the mutation. Thrombosis on OCPs, cerebral vein thrombus, DVT/PE in white population.
Anriphospholipid antibody syndrome tests
Anti-cariolipin antibody, anti-beta-2 glycoprotein antibody, lupus anticoagulant. For unexplained VTE, CVA/TIA at less than 50 years old, recurrent VTE, unusual site, artery and venous thrombosis, thrombocytopenia, recurrent early pregnancy loss.
IVC filter indications
Anticoagulation is contraindicated, recurrent PE even with anticoagulation, hemodynamic/respiratory compromise where another PE would be life threatening.
Thrombolytic use for PE indications
unstable patients with shock , hypoxemia, V/Q deficit, RV dysfunction, extensive DVT. (strptokinase, urokinase, recombinant tissue plasminogen activator).
